There's no shortage of doctors in Pittsburgh. And with her good health coverage, Meredith Wills could see almost any of them. But the 25-year-old law-school grad prefers to visit nurse practitioner Mona Counts in Mt. Morris, Pa., a 55-mile drive south. Wills has nothing against doctors. She simply likes Counts's combination of medical skills and down-to-earth manner. She likes them so much, she's even willing to pay Counts out of pocket. "Mona has this way of observing the overall person in front of her," says Wills, whose fiance, himself a former nurse, introduced her to the NP eight years ago. "Three years ago my mom had open-heart surgery, and I was in my first year of law school," Wills recalls. "Every time I visited her office, Mona always remembered to ask about my mom. I think it's because she knew my mom's health affected my health. Even now, Mona goes well above and beyond just doctoring."
The appeal of NPs as primary-care providers isn't hard to fathom. Well schooled in medicine, they also possess the kind of nurturing and educational skills that too many doctors lack. In an age of assembly-line medicine, NPs take time with patients, listening and counseling in equal measures. It's that unhurried style that makes them popular with patients--and extremely valuable to doctors harried by managed-care systems. According to the American Academy of Nurse Practitioners, more than a quarter of the nation's 80,000 NPs work in doctor-run solo and group practices. An additional 10 percent or so captain their own practices. And the rest work in places like hospitals, community health centers, nursing homes and home health agencies.
Popular as NPs are, however, some doctors feel threatened. Under pressure from organized medicine, 10 states still require doctor supervision of NPs and other advanced practice nurses, including nurse midwives, nurse anesthetists and clinical nurse specialists. Most of the remaining states insist on collaboration (close or frequent consultation), but not supervision. The paternalism stings. "I've found that competent physicians don't have a problem with NPs," says Mona Counts. "It's the marginalized ones that do."
Before you select an NP for your primary care, here are a few things to keep in mind:
First, unless you're willing to dig into your own pocket, determine whether your health insurer pays for NP services. Fortunately, more and more health plans are starting to include NPs and other APNs on their list of providers. Be cautious, though. Some plans include NPs in their networks as specialists. In such cases, you'll need to see a primary-care physician before being allowed to see an NP provider. If you're over 65, access is easier. In 1997, Congress extended Medicare to cover NP and clinical nurse specialist services regardless of geographical location. (Previously, only services in rural areas were covered.)
Next, check medical education and licenses. Has the NP earned the master's degree required for entry-level practice? Some NPs today also hold doctorates in nursing, or other advanced degrees. NPs, like doctors, are state-regulated; contact your state nursing board for any license restrictions or disciplinary actions. (Most states now post this information on the Internet.) Also ask if state law imposes any limits on an NP's scope of practice or prescription authority. In every state except Georgia, for example, NPs are licensed to prescribe medications under their own signatures. But not every state extends this authority to controlled substances, and the 42 that do vary in the types or "schedules" of controlled substances NPs are permitted to prescribe. To locate your state nursing board, go to the Web site of the National Council of State Boards of Nursing www.ncsbn.org), click on "Nursing Regulation" then "Boards of Nursing" and then "Contact Information and Web sites."
Talk to your NP about her clinical expertise and professional background, just as you would if you were selecting a new doctor. If a specific area like adult medicine, women's health or family practice is important to you, ask about her specialty training and board status. Like doctors, advanced practice nurses enhance their professional standing and expertise by becoming nationally certified in their specialty area. Also check years in practice--and whether your NP enjoys hospital-admitting privileges. If not, don't be alarmed: some beginning and even midcareer doctors don't, either. Increasingly, however, hospitals are beginning to come around. "We're working to make sure admitting privileges aren't a barrier to NP practice," says Dr. Jan Towers of AANP.
Finally, look at the Web site of the American Academy of Nurse Practitioners (www.nurse.org/aanp). Other sources of information include the National Association of Clinical Nurse Specialists (nacns.org), the American College of Nurse-Midwives (acnm.org) and the American Association of Nurse Anesthetists (aana.com). You might also read a book on the subject of nonphysician practitioners called "Not What the Doctor Ordered: How to End the Medical Monopoly in Pursuit of Managed Care," by Jeffrey C. Bauer, Ph.D.
NPs may not be what every doctor ordered. But they could suit your style of health care just fine.